Three quick steps and we’ll be ready for your first session!

Step 1 is the intake form – just some questions so I can get to know how best to support and assist you.

Step 2 is make an appointment; find a day and time that best fits your schedule.

Step 3 is about payment options. Select hourly rate, sliding scale, and if neither of those are available to you, no cost options.

Client Intake Form

Confidentiality: Your information is kept confidential except where required by law.
Hypnotherapy Disclaimer: Hypnotherapy is not a substitute for medical or psychological diagnosis and treatment. Please consult your healthcare provider for concerns outside the scope of hypnotherapy.

First Name (required)

Last Name (required)

Email Address (required)

Phone Number (required)

Date of Birth (required)

Pronouns

City

State/Province

Country

Medical & Mental Health History

Do you have any current medical conditions we should be aware of?

Are you currently taking any medications?

Have you been diagnosed with any mental health conditions?

Are you currently working with a therapist or counselor?

YesNo

Additional Information

How did you hear about me?

If referred by someone, please provide their name:

Is there anything else you’d like us to know?

Consent & Agreement

I understand that hypnotherapy is not a substitute for medical or psychological treatment, and I have consulted or will consult my healthcare provider as needed.

I consent to participating in hypnotherapy sessions and understand I can withdraw consent at any time.

I acknowledge that my information will be kept confidential except where required by law.

Schedule Your Appointment

(This assume virtual via Zoom; if we are meeting in person, then please contact me via email for that process).

Payment Options

I am currently only accepting donations. After our session, I’ll send you a link that will allow you to donate if you are able.

Schedule Your First Session